大手术围术期液体管理策略：分层荟萃分析

背景尽管开放性和目标导向（goal—directed,GD）的液体治疗在围术期都应用大量液体,但两者对围术期预后的影响却明显不同。我们致力于判断是否某种管理策略优于其他策略。方法我们从MEDLINE、EMBASE、PubMed（1951—2011．4）以及注册的Cochrane对照试验中选择在大手术中应用GD或限制性与开放性（restrictive versus liberal,LVR）液体治疗的随机对照试验（randomized controlled trials,RCTs）,不设语言限制。GD和LVR两层进行间接比较。结果该研究纳入来自23项GDRCT[样本量中位数=90,四分位距（interquartile range,IQR）57～JD9]的3861例患者和来自12项LVRRCT（样本中位数=80,IOR36一J5J）的1160例患者。开放性和GD液体治疗均比其相应的对比策略应用更多液体,但两者对结果的影响却明显不同。开放性补液与限制性液体治疗患者比较,肺炎[风险比（riskratio,RR）2．2,95％可信区间[（confidenceinterval,CI）J．0～4．5J和肺水肿（RR3．8,95％CIJ．J—J3）风险更高,住院时间更长[平均差异（mean difference,MD）2天,95％C10．5。3．4]。与非GD液体治疗患者比较,GD治疗患者的肺炎风险（RR0．7,95％C10．6—0．9）和肾脏并发症（RR0．7,95％C10．5。0．9）减少,住院时间缩短（MD2天,95％CIJ一3）。与GD治疗患者比较,开放性液体治疗患者住院时间延长（4天。95％CI3．4～4．4）、肠蠕动恢复时间延长（2天,95％CIJ．j～2．3）、肺炎风险增加（足足月3,95％CIJ．8～4．8）。结论GD液体治疗比无血流动力学目标指导的开放性液体治疗的围术期预后更好。但GD液体治疗是否优于限制性液体治疗仍不确定。     

Postoperative blood transfusion strategy in frail,anemic elderly patients with hip fracture

Background and purpose — Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.

Patients and methods — We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.

Results — No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1–5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1–3.6; p = 0.01).

Interpretation — According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.     

A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators.

Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective. IMPLICATIONS: This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.     

Perioperative blood transfusion in anemic patients undergoing elective endovascular abdominal aneurysm repair

ObjectiveAlthough blood transfusion can be lifesaving in active hemorrhage or severe anemia, it is also associated with increased morbidity and mortality. Several trials have established this risk and therefore defined a restrictive standard for transfusion, but this threshold and the risk of transfusions have not been specifically examined in vascular surgery patients. We therefore sought to assess transfusion practices and outcomes of anemic patients undergoing elective endovascular aneurysm repair (EVAR).MethodsThe Vascular Quality Initiative database was queried for patients undergoing EVAR between the years 2008 and 2017. Anemic patients were included in the study and were further stratified into mild anemia, defined by a hemoglobin level of 10 to 13 g/dL in men or 10 to 12 g/dL in women, and moderate to severe anemia, defined by a hemoglobin level <10 g/dL. The primary study outcomes were in-hospital mortality and complications.ResultsAmong 27,777 EVAR patients, one-third (n = 9232) were anemic and included in the study. One-fifth (n = 1866) of anemic patients received a perioperative transfusion. Transfused patients were more likely to have a history of cardiovascular disease. In-hospital mortality was significantly higher for anemic patients who received transfusions, both in mild anemia (mortality, 3.6% vs 0.4% in no transfusion; P < .001) and in moderate to severe anemia (4.5% vs 1.3%; P < .01). Morbidity was also significantly higher, with anemic patients who received a transfusion having higher rates of myocardial infarction, congestive heart failure, dysrhythmias, renal complications, leg ischemia, respiratory complications, and reoperation compared with anemic patients who did not receive any transfusion. The 30-day mortality was also higher in transfused patients (P < .001). After adjustment for patients' demographics, comorbidities, and operative factors, transfusion in anemic patients was associated with a nearly 4.4-fold increased odds of in-hospital mortality (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.72-7.05; P < .001) and 4.3-fold higher odds of any in-hospital complication (OR, 4.31; 95% CI, 3.47-5.34; P < .001). This was more pronounced among patients with mild anemia, with 5.7 times (OR, 5.7; 95% CI, 1.78-18.0) and 4.3 times (OR, 4.3; 95% CI, 3.46-5.29) the odds of in-hospital mortality and complications, respectively.ConclusionsAmong anemic patients undergoing elective EVAR, transfusion is associated with an increased risk of death and in-hospital complications, even after controlling for patients' comorbidities and operative factors. These data suggest that the restrictive use of blood transfusions might be safer in vascular surgery EVAR patients. Medical management of anemia may be warranted in these patients to reduce morbidity and mortality; however, further studies are needed to evaluate effectiveness.     

围手术期目标导向容量治疗用于预防腹部手术后胃肠道并发症的Meta分析

目的 评价围术期目标导向容量治疗对预防腹部手术后胃肠道并发症的有效性,为制定临床合理的个体化容量治疗方案提供理论依据.方法 计算机检索Cochrane图书馆(2010年第3期)、PubMed、EMbase、Highwire、CBM、CNKI等中外生物医学数据库.收集关于围手术期目标导向容量治疗对预防腹部手术后胃肠道并发症方面的临床随机对照试验,检索日期由2000年1月至2010年12月.按Cochrane系统评价方法,评价所纳入研究的文献质量,并提取有效数据后采用RevMan5.0软件进行Meta分析.结果 纳入10项研究,共计775例患者.Meta结果 显示:目标导向容量治疗可显著提高机体氧供(WMD=82.95,95%CI:17.43～148.46),降低胃肠道术后并发症的发生率(RR=0.39,95%CI:0.29～0.52),并缩短住院天数(WMD=-2.06,95%CI:-2.95～-1.17).结论 围手术期目标导向容量治疗可以有效预防术后胃肠道并发症的发生.

Abstract：

Objective To assess whether goal-directed fluid management can prevent gastrointestinal complications in major surgery. Methods Electronic databases including Cochrane library (Issue 3,2010), Pubmed, EMbase, Highwire, CBM, and CNKI were searched. The date of search was between January 2000 and December 2010. Randomized controlled trials (RCTs) were indentified studying association of goal-directed therapy (GDT) with gastrointestinal complications. Study selection and meta-analysis were conducted according to the Cochrane Handbook for systematic reviews. Data were extracted from these trials by 3 reviewers independently and analyzed by RevMan5.0 software. Results Ten trials involving 775 patients were included. GDT significantly improved oxygen supply (WMD=82.95, 95% CI: 17.43-148.46). GDT reduced postoperative hospital stay (WMD=-2.06, 95% CI:-2.95——1.17) and decreased postoperative complication rate after major surgery(RR=0.39, 95% CI: 0.29-0.52). Conclusion Goal-directed fluid management can stabilize cardiac output, augment oxygen supply, and therefore reduce postoperative complications.     

Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions

BACKGROUND: Preoperative investigation and treatment of anaemia is recommended before orthopaedic surgery. We measured the prevalence of anaemia among admissions presenting for elective major joint arthroplasty (MJA), assessed their transfusion requirements, and investigated factors associated with perioperative blood transfusion. METHODS: All admissions to a dedicated elective orthopaedic hospital during 2000-2001 were studied. The patients' database was merged with the haematology and transfusion databases. Population estimates for different types of anaemia and their blood transfusion requirements were generated using local reference ranges (males <130 g litre(-1); females <115 g litre(-1)). RESULTS: One thousand three hundred and twenty-two admissions were included; haematology data were complete for 1142 (544 primary hip, 490 primary knee, 77 revision hip, 31 revision knee). About 19.6% were anaemic [7.1% haemoglobin (Hb) <110 g litre(-1); 1.6% Hb<100 g litre(-1)]. Overall, 21.3% of admissions were transfused (mean 0.58 units per case: 95% CI 0.50-0.61). For anaemic admissions, 42.0% were transfused (mean 1.11 units per case: 95% CI 0.90-1.32). Mean red cell use for admissions with normocytic normochromic anaemia (12.7% of admissions) and hypochromic anaemia (4.6%) was 1.04 (95% CI 0.78-1.31) and 1.14 (95% CI 0.71-1.57) units per admission, respectively. Factors strongly associated independently with transfusion were preoperative haemoglobin 相似文献   

Timing and safety of hip fracture surgery in patients on direct-acting oral anticoagulants

BackgroundMany geriatric patients presenting for emergency hip fracture surgery are on direct oral anticoagulants (DOACs) most of which are not easily reversible. A safe policy was required to reduce delays to surgery. Prior to institution of our hospital's protocol in January 2021, most of these patients had surgery after 48 h following the last dose of DOAC due to concerns about increased perioperative blood loss.MethodsThis was a prospective closed loop audit of the protocol-surgery within 24 h from last dose of DOAC (if creatinine clearance >50 ml/min) with administration of 1-g of tranexamic acid at anesthesia induction. 131 eligible patients (DOAC, n = 22; no anticoagulation, n = 109) between January–June 2021 who had emergency hip fracture surgery were identified. Primary outcome measures were peri-operative blood loss, transfusion requirements and policy compliance. Secondary outcome measures were 30-day mortality, thrombotic complications and wound bleeding.ResultsCompliance with surgical timing and tranexamic acid administration were 55% and 81% respectively after the second audit cycle. The mean estimated blood loss (EBL) in the DOAC group versus the non-anticoagulated control group was 500 ml and 330 ml respectively. The difference between these groups was statistically significant at an alpha level of 5% (P = 0.0115, 95% CI 38.48–299.16). The difference for intra-operative (RR 3.43; 95% CI 1.68–7.01) and post-operative blood transfusion (RR 2.10; 95% CI 1.23–3.58) for the 2 groups was also statistically significant. However, there was no case of massive blood transfusion in both groups. The DOAC group had a lower risk for 30-day mortality (RR 0.71; 95% CI 0.09-5.46). There was no major thrombotic complication in the DOAC group.ConclusionThis audit has shown that this protocol is safe although clinicians should anticipate some degree of increased intra-operative blood loss. We will recommend continuation of this policy with sustained safety monitoring in order to reduce delays to surgery.     

Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina?

Background

Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors.

Methods

Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not.

Results

There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1).

Conclusions

Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment.     

胃癌根治术腹主动脉旁淋巴结清扫安全性与有效性的Meta分析

目的评价胃癌根治术腹主动脉旁淋巴结清扫的安全性与有效性。方法2位评价者制定检索策略,利用PubMed和Medline等数据库检索胃癌手术腹主动脉旁淋巴结清扫的随机对照研究,运用固定效应模型与随机效应模型对术中腹主动脉旁淋巴结清扫与否的两组胃癌患者手术的安全性与有效性进行Meta分析。结果符合入选标准的随机对照临床试验7项共计胃癌根治术患者1446例。与非腹主动脉旁淋巴结清扫组比较,腹主动脉旁淋巴结清扫组患者术后并发症总发生率升高（RR1．34,95％CI1．03～1．75,P=0．03）：术后出现淋巴瘘和严重腹泻者增多（RR分别为16．23和9．56,95％CI分别为1．99～131．98和1．70～53．67）;而术后吻合口瘘、胰瘘、腹腔脓肿、肠梗阻、出血和伤口感染等发生率未见明显升高。腹主动脉旁淋巴结清扫组术中出血量及输血人数比例增加（WMD202．95,95％CI116．80．289．10：RR1．93,95％CI1．20。3．10：均P〈0．05）,但手术时间、平均输血量、平均术后住院天数、再次手术率、术后复发率和5年生存率等与D2／D3术式相近。结论腹主动脉旁淋巴结清扫术后并发症总发生率升高,并不能降低术后复发率、提高生存率,其临床疗效尚有待更严格的、多中心的、具有长期随访的大宗病例研究来证实。     

Hepatectomy for hepatocellular carcinoma: the surgeon's role in long-term survival.

HYPOTHESIS: The surgeon can contribute substantially to the long-term survival rate of patients undergoing hepatectomy for hepatocellular carcinoma (HCC). DESIGN: The long-term survival rate of patients with HCC undergoing hepatectomy has improved, but the contribution of the surgeon to the improved survival rate is unknown. We surveyed 211 consecutive patients undergoing hepatectomy for HCC. The clinical, operative, and pathological factors were analyzed to identify factors that were important in affecting long-term survival. SETTING: A tertiary referral center. PATIENTS: From April 1989 to December 1995, 211 consecutive patients with HCC underwent 153 major and 58 minor hepatectomies. MAIN OUTCOME MEASURES: Disease-free and overall cumulative survival rate. RESULTS: The 5-year disease-free survival rate was 27%. By Cox regression analysis, blood transfusion (relative risk [RR], 1.21; 95% confidence interval [CI], 1.05-1.40) and TNM stage (RR, 1.90; 95% CI, 1.47-2.47) were shown to be independent prognostic factors in the 5-year disease-free survival rate. The 5-year overall cumulative survival rate was 37%. By Cox regression analysis, the preoperative indocyanine green retention value at 15 minutes after injection (RR, 1.03; 95% CI, 1.01-1.06), blood transfusion (RR, 1.191; 95% CI, 1.078-1.316), tumor rupture (RR, 1.48; 95% CI, 1.08-2.04), and TNM stage (RR, 1.62; 95% CI, 1.27-2.07) were shown to be significant independent factors that influenced cumulative survival rate. CONCLUSIONS: The long-term survival of patients with HCC after hepatectomy depends on tumor staging, preoperative hepatic functional reserve, history of blood transfusion, and rupture of HCC. Preoperative liver function and tumor staging cannot be altered; however, the surgeon can play an important role in improving the prognosis if blood transfusion and iatrogenic tumor rupture can be avoided and if function of the liver remnant can be preserved.     

Leucocyte-Depleted Blood Transfusion is an Independent Predictor of Surgical Morbidity in Patients Undergoing Elective Colon Cancer Surgery—A Single-Center Analysis of 531 Patients

Background

Leukocyte-depleted packed red blood cells (PRBC) were introduced to reduce potential immunomodulatory effects and transfusion-associated morbidity. It has, however, remained unclear, if leucocyte depletion prevents negative side effects of blood transfusion. The aim of this analysis was to examine the effects of leukocyte-depleted PRBC on surgical morbidity after elective colon cancer surgery.

Methods

Data were prospectively collected from 531 consecutive patients undergoing elective colon cancer surgery at a single high-volume center (University Hospital) from 2002 to 2008. Potentially predictive factors for surgical morbidity were tested on univariate and multivariate analysis.

Results

A total of 531 patients with colon cancer were included. A curative (R0) resection was performed in 497 patients (94%). The mortality rate, overall morbidity rate, and surgical morbidity rate were 1.1, 33, and 21%, respectively. Some 135 patients (25%) received perioperative transfusion of PRBCs. On multivariate analysis age (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02–1.06; P = 0.001), BMI (OR 1.08, 95% CI 1.03–1.13; P = 0.003), and PRBC transfusion (2.4, 1.41–4.11; P = 0.001) were revealed as independent predictors of surgical morbidity. The risk of surgical complications increased continuously with the amount of transfused PRBCs. The adverse impact of PRBC transfusion was neither restricted to the timepoint of transfusion (intraoperative or postoperative), nor to the kind of complication (infectious vs noninfectious complication).

Conclusion

Perioperative transfusion of leukocyte-depleted PRBCs has a significantly negative effect on surgical morbidity of patients undergoing elective colon cancer surgery. The use of perioperative blood transfusions in these patients should be avoided, whenever possible.     

The role of point‐of‐care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta‐analysis

This systematic review and meta‐analysis appraises the utility of point‐of‐care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta‐analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow‐up (mean difference ?102.9 ml (95% CI ?149.9 to ?56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78?0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30?0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference ?111.8 ml (95% CI ?174.9 to ?49.1 ml), p = 0.0005) compared with their use alone (mean difference ?90.6 ml (95% CI 166.1?15.0 ml), p = 0.02). We conclude that incorporation of point‐of‐care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.     

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to monitor haemostatic treatment in bleeding patients: a systematic review with meta‐analysis and trial sequential analysis

Coagulopathy and severe bleeding are associated with high mortality. We evaluated haemostatic treatment guided by the functional viscoelastic haemostatic assays, thromboelastography or rotational thromboelastometry in bleeding patients. We searched for randomised, controlled trials irrespective of publication status, publication date, blinding status, outcomes published or language from date of inception to 5 January 2016 in six bibliographic databases. We included 17 trials (1493 participants), most involving cardiac surgery. Thromboelastography or rotational thromboelastometry seemed to reduce overall mortality compared to any of our comparisons (3.9% vs. 7.4%, RR (95% CI) 0.52 (0.28–0.95); I² = 0%, 8 trials, 717 participants). However, the quality of evidence is graded as low due to the high risk of bias, heterogeneity, imprecision and low event rate. Thromboelastography or rotational thromboelastometry significantly reduced the proportion of patients transfused with red blood cells (RR (95% CI) 0.86 (0.79–0.94); I² = 0%, 10 trials, 832 participants), fresh frozen plasma (RR (95% CI) 0.57 (0.33–0.96); I² = 86%, 10 trials, 832 participants) and platelets (RR (95% CI) 0.73 (0.60–0.88); I² = 0%, 10 studies, 832 participants). There was no difference in proportion needing surgical re‐interventions (RR (95% CI) 0.75 (0.50–1.10); I² = 0%, 9 trials, 887 participants). Trial sequential analysis of mortality suggests that only 54% of the required information size has been reached so far. Transfusion strategies guided by thromboelastography or rotational thromboelastometry may reduce the need for blood products in patients with bleeding, but the results are mainly based on trials of elective cardiac surgery involving cardiopulmonary bypass, with low‐quality evidence.     

Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s.

OBJECTIVES: To compare the efficacy of combined oral and systemic antibiotics (combined) versus systemic antibiotics (systemic) alone in preventing surgical site infection in elective surgery of the colon, and to perform a meta-analysis of randomized studies comparing combined versus systemic antibiotics in elective colon surgery. DESIGN: A double-blind, placebo-controlled, randomized clinical trial. SETTING: The Queen Elizabeth Hospital, Montreal, a university-affiliated community hospital. PARTICIPANTS: Two hundred and fifteen patients scheduled to undergo elective surgery of the colon. INTERVENTIONS: Patients were randomized to receive neomycin and metronidazole orally (109 patients) or identical placebos (106 patients) on the final preoperative day. All were given amikacin and metronidazole intravenously just before operation. Thirteen randomized series comparing combined and systemic antibiotic prophylaxis in elective colon surgery were identified for meta-analysis. OUTCOME MEASURES: Rates of postoperative surgical site infections: risk differences, risk ratios (RRs) and 95% confidence intervals (CIs); organisms found in the colon and wound fat at surgery, and in infected wounds. RESULTS: Three patients in the systemic group, and 5 in the combined group were excluded. Wound infections occurred in 5 patients in the combined group but in 17 in the systemic group (p < 0.01, RR = 0.29, 95% CI 0.11-0.75). Bacteria isolated from wound infections and wound fat were similar to those found in the colon. They were more frequent in the colon in the systemic group (p < 0.001) and occurred in wound fat in the systemic group twice as often as in the combined group (p < 0.001). By stepwise logistic regression, the presence of bacteria in wound fat at surgery was the strongest predictor of postoperative wound infection (p < 0.002). In the meta-analysis, the summary weighted risk difference in surgical site infections between groups (d(w)) and the summary RR both favoured combined prophylaxis (d(w) = 0.56, 95% CI 0.26-0.86; RR = 0.51, 95% CI 0.24-0.78; p < 0.001). CONCLUSIONS: In elective surgery of the colon combined oral and systemic antibiotics are superior to systemic antibiotics in preventing surgical site infections. Orally administered antibiotics add value by reducing bacterial loading of the colon and wound fat contamination, both associated with postoperative wound infection. Meta-analysis of randomized clinical trials reported from 1975 to 1995 supports these conclusions.     

Variability in Transfusion Practice for Coronary Artery Bypass Surgery Persists Despite National Consensus Guidelines: A 24-Institution Study

Background: An estimated 20% of allogeneic blood transfusions in the United States are associated with cardiac surgery. National consensus guidelines for allogeneic transfusion associated with coronary artery bypass graft (CABG) surgery have existed since the mid- to late 1980s. The appropriateness and uniformity of institutional transfusion practice was questioned in 1991. An assessment of current transfusion practice patterns was warranted.

Methods: The Multicenter Study of Perioperative Ischemia database consists of comprehensive information on the course of surgery in 2,417 randomly selected patients undergoing CABG surgery at 24 institutions. A subset of 713 patients expected to be at low risk for transfusion was examined. Allogeneic transfusion was evaluated across institutions. Institution as an independent risk factor for allogeneic transfusion was determined in a multivariable model.

Results: Significant variability in institutional transfusion practice was observed for allogeneic packed red blood cells (PRBCs) (27-92% of patients transfused) and hemostatic blood components (platelets, 0-36%; fresh frozen plasma, 0-36%; cryoprecipitate, 0-17% of patients transfused). For patients at institutions with liberal rather than conservative transfusion practice, the odds ratio for transfusion of PRBCs was 6.5 (95% confidence interval [CI], 3.8-10.8) and for hemostatic blood components it was 2 (95% CI, 1.2-3.4). Institution was an independent determinant of transfusion risk associated with CABG surgery.     

Effect of intraoperative fluid management on outcome after intraabdominal surgery

BACKGROUND: The debate over the correct perioperative fluid management is unresolved. METHODS: The impact of two intraoperative fluid regimes on postoperative outcome was prospectively evaluated in 152 patients with an American Society of Anesthesiologists physical status of I-III who were undergoing elective intraabdominal surgery. Patients were randomly assigned to receive intraoperatively either liberal (liberal protocol group [LPG], n = 75; bolus of 10 ml/kg followed by 12 ml x kg(-1) x h(-1)) or restrictive (restrictive protocol group [RPG], n = 77; 4 ml x kg(-1) x h(-1)) amounts of lactated Ringer's solution. The primary endpoint was the number of patients who died or experienced complications. The secondary endpoints included time to initial passage of flatus and feces, duration of hospital stay, and changes in body weight, hematocrit, and albumin serum concentration in the first 3 postoperative days. RESULTS: The number of patients with complications was lower in the RPG (P = 0.046). Patients in the LPG passed flatus and feces significantly later (flatus, median [range]: 4 [3-7] days in the LPG vs. 3 [2-7] days in the RPG; P < 0.001; feces: 6 [4-9] days in the LPG vs. 4 [3-9] days in the RPG; P < 0.001), and their postoperative hospital stay was significantly longer (9 [7-24] days in the LPG vs. 8 [6-21] days in the RPG; P = 0.01). Significantly larger increases in body weight were observed in the LPG compared with the RPG (P < 0.01). In the first 3 postoperative days, hematocrit and albumin concentrations were significantly higher in the RPG compared with the LPG. CONCLUSIONS: In patients undergoing elective intraabdominal surgery, intraoperative use of restrictive fluid management may be advantageous because it reduces postoperative morbidity and shortens hospital stay.     

Transfusion Thresholds for Major Orthopedic Surgery: A Systematic Review and Meta-analysis

Background

More than a million surgeries are performed annually in the United States for hip or knee arthroplasty or hip fracture stabilization. One-fifth of these patients have blood transfusions during their hospital stay. Increases in transfusion rates have caused concern about increased adverse events from unnecessary transfusions.

Mortality and Complications in Patients with Metastatic Disease after Primary Total Hip and Total Knee Arthroplasty

BackgroundAlthough palliative therapies such as radiation are usually performed to improve quality of life in patients with metastatic disease, arthroplasty for joint pain may be indicated in some cases. Therefore, the purpose of this study is to evaluate the 30-day mortality risk, the risk of complications including infection and venous thromboembolic events, and the rate of 30-day reoperations and readmissions in patients with metastatic disease undergoing primary total hip and total knee arthroplasty (THA/TKA).MethodsWe reviewed the National Surgical Quality Improvement Program database from 2008 to 2018 to evaluate rates of postoperative complications after elective primary THA/TKA in patients with disseminated cancer. After exclusions, 205,007 patients undergoing primary THA and 352,337 undergoing primary TKA were retained for analysis: 942 (0.2%) with disseminated cancer. Chi-square was used to compare proportions between groups. Univariate and multivariate logistic regression was used to model the odds ratio of patients with disseminated cancer compared with those without disseminated cancer.ResultsAfter adjustment for covariates, patients with disseminated cancer had a higher risk of death (OR: 5.25, 95% CI: 2.47-11.17), any complication (OR: 1.95, 95% CI: 1.63-2.33), deep venous thrombosis (OR: 2.39, 95% CI: 1.32-4.35), pulmonary embolism (OR: 3.07, 95% CI: 1.52-6.17), cardiovascular complications (OR: 2.98, 95% CI: 1.47-6.04), transfusion (OR: 2.21, 95% CI: 1.82-2.69), reoperations (OR: 1.89, 95% CI: 1.28-2.78), readmissions (OR: 2.51, 95% CI: 1.95-3.23), and longer length of stay (4.3 vs 2.7 days).ConclusionPatients with disseminated cancer have significantly elevated risk of complications after elective primary THA/TKA. Understanding the severity of complications is critical to the risk-benefit analysis that confronts patients and surgeons considering surgery.Level of EvidenceII.     

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE: To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival. SUMMARY BACKGROUND DATA: The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival. METHODS: Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis. RESULTS: We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001). CONCLUSIONS: In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.     

Blood loss and transfusion in elective abdominal aortic aneurysm surgery

BACKGROUND: Intraoperative blood loss and transfusion are known determinants of mortality and morbidity of elective abdominal aortic aneurysm (AAA) repair. The present study analysed the pattern of blood loss and transfusion and evaluated the risk factors of blood loss during open repair of infrarenal AAA. METHODS: Blood loss, transfusion and fluid replacement during elective open repair operation for patients with infrarenal AAA were correlated to demographic data, operative findings and procedural information. RESULTS: A total of 129 patients with a mean age of 71 years was analysed. The mean blood loss was 1000 +/- 887 mL (200-6000 mL). Blood transfusion, with a mean transfusion volume of 400 +/- 591 mL (0-3000 mL), was required in 46% of patients. Univariate analysis showed that bodyweight, renal impairment, low haemoglobin and platelet counts, iliac artery involvement, large aneurysm, bifurcated graft, large graft diameter, prolonged aortic clamp time and long operation time were associated with a higher blood loss. A haemoglobin level of <10.5 g/dL (relative risk (RR): 4.6), platelet count <130 x 10(9)/L (RR: 3.9), aortic clamp time >50 min (RR: 15), total operation time >200 min (RR: 11) and type of graft (RR: 3.5) were identified as independent determinants of blood loss on multivariate analysis. CONCLUSION: Intraoperative blood loss in elective infrarenal aneurysm surgery is influenced by patients' haematological parameters, distal involvement of aneurysm and degree of difficulty of operation.